What is swimmer’s shoulder?
The short answer is swimmer’s shoulder refers to non-specific pain in the shoulder, because of swimming.
Swimmer’s shoulder can affect several different structures in the shoulder so the symptoms are not the same for everyone. For example, you may experience pain in the back of the shoulder after a period of time in the water, or perhaps more of a pinch in the top, at a specific moment in your stroke.
Depending on the underlying cause of your swimmer’s shoulder, treatment will vary. You can often continue swimming if you catch it early and make the appropriate modifications to your training volume and/or technique.
In the most severe cases, if left untreated, swimmer’s shoulder can result in tendon degeneration and rotator cuff tears.
Let’s learn about the relevant anatomy and mechanics of the shoulder while swimming, what causes swimmer’s shoulder, what the symptoms are, how to treat it, and how to minimize your risk of developing it.
Understanding the anatomy and mechanics of the shoulder can help us understand how injury develops in an otherwise strong and pain-free shoulder.
The bones of the shoulder joint include the scapula (shoulder blade), clavicle (collar bone), and humerus (arm). There is a very small surface area where the bones articulate with each other, which means it is an inherently unstable joint. This type of joint allows for maximum range of motion, but requires cartilage, ligaments, and muscle tendons to ensure the arm stays securely in the shoulder socket.
The muscles play several important roles in optimal shoulder function. The rotator cuff works to properly position the head of the humerus in relation to the shoulder blade; while the scapula stabilizers hold the shoulder blade in position to create a stable base for the arm to rotate around. Finally, we have larger power muscles responsible for gross movements.
The rotator cuff muscles play an important role by properly positioning the head of the humerus in relation to the scapula. The rotator cuff is extremely susceptible to injury while swimming. The supraspinatus often gets ‘pinched’ when the arm is raised, leading to pain and inflammation; whereas the infraspinatus and subscapularis muscles are active throughout the entire swimming stroke and are vulnerable to fatigue and overuse injury.
The role of the scapula stabilizers (rhomboids, serratus anterior, and upper traps) is to create a stable platform for the arm to rotate around and push off. Similar to the rotator cuff, serratus anterior is active during the pull through, as well as during hand entry/exit to stabilize the shoulder blade.
The power muscles in swimming are primarily the pecs, lats, and deltoids. These larger, more powerful muscles work phasically in the stroke – meaning they switch on and off at different times when required. For example, the deltoid positions the humeral head for the pull, the pecs are the prime mover from the catch and the top half of the pull through, while the lats take over for the second part of the pull through.
What causes swimmer’s shoulder?
There are essentially two patterns of injury that lead to swimmer’s shoulder. It most often develops as a result of fatigue, or faulty mechanics, either of which can be intensified by certain anatomical predispositions that put you at a higher risk of developing this type of injury.
Fatigue becomes an issue if you have recently tried to increase your training distance and/or frequency too suddenly. Certain structures, such as the serratus anterior and infraspinatus are particularly susceptible to fatigue. If they do not have the endurance required to meet the demands, we get compensation from other muscles, sub-optimal control, overuse problems, and changes in technique.
Faulty mechanics or poor technique can put certain structures in the shoulder (commonly the supraspinatus) in a vulnerable position creating less space in the shoulder joint for muscles to move without getting pinched, and causes excess strain by recruiting the incorrect muscles. For example, crossing over past the midline of the body during hand entry and pull phase, or having the hand higher than the elbow on the recovery phase are common errors which put excess stress and increase the risk of impingement in the shoulder.
Anatomical predispositions such as hyper or hypo-mobility of the shoulders (if you’re unusually flexible or stiff), as well as variations in the shape of the bony structures in your shoulder can increase your risk of developing swimmer’s shoulder. As a side note, there is a bit of a misconception among swimmers who believe that excessive range of motion in the shoulders is necessary to be an elite level swimmer. The actuality is that it requires more muscle activation to stabilise the shoulder when you’re hyper-flexible, which makes you more susceptible to fatigue and increases your risk of developing swimmer’s shoulder.
Whether it is fatigue, faulty mechanics, or a predisposition, essentially the result is the same. The shoulder blade moves out of it’s optimal position because the rotator cuff muscles are either too tired, or not in the correct position to stabilise it. This results in either jamming or pinching of certain rotator cuff tendons, or overuse/excessive strain on others. If this continues repetitively, the impinged tendon gets inflamed, which creates more friction and makes the problem worse. Eventually the tendons start to break down (known as tendinosis), meaning they become very weak and brittle, and susceptible to tearing.
How do I know I have it?
Swimmer’s shoulder can affect several different structures depending on what is causing the problem. Saying that, not everyone will experience the same type of symptoms.
Some, for example might notice pain in the back of the shoulder after 25-30 minutes of swimming, while others may experience a sharper pinching feeling in the top of the shoulder at the same point in every stroke cycle.
In the early stages, it is sometimes not obvious that there is a problem at all, particularly if it is a fatigue issue. If it takes 20 or 45 minutes of swimming for your symptoms to come on, they will be difficult to pick up in a clinical setting because the shoulder is not necessarily damaged yet. This is the time however, that you need to address the problem.
With swimmer’s shoulder, you want to be looking for subtle signs of injury BEFORE it develops into structural damage.
How do you treat swimmer’s shoulder?
Treatment again will depend on the underlying cause of your shoulder pain and I certainly recommend you seek advice from your coach and/or physio to create an optimal plan for you. Depending on the severity of the injury, you do NOT necessarily have to stop swimming, but you will need to modify the quantity and/or your technique.
The type of treatment you can expect from a physio would include soft tissue work and manual therapy on the involved muscles, but more importantly they will address any imbalances which may exist as a result of weakness, stiffness, or instability. Unfortunately, this isn’t an overnight fix but you should end up with an individualized program that includes mobility exercises, neuromuscular re-education for scapula control, and rotator cuff endurance and strengthening.
Unfortunately, if the injury has already progressed to a tendinopathy, you likely will need to take a break from swimming to rest it appropriately, use anti-inflammatories to control the symptoms, and start on an eccentric training program to re-build the tendon strength.
Equally important is addressing your swimming technique so again, I would advise seeking professional advice from a coach to avoid worsening shoulder pain or recurrences in the future.
How to prevent swimmer’s shoulder
The best way to prevent swimmer’s shoulder is to focus on proper technique, and build volume gradually. I’ve listed a few technique pointers below to help you focus on some key parts of the stroke:
- Watch the position of your hand relative to the elbow when it exits the water for the recovery. High elbow, low wrist. You should never have your hand coming above your elbow
- Keep the recovery hand relatively wide (but not too wide) as it is less likely to cause impingement compared to a really narrow one
- Be careful not to cross the centre line of your body. Hand should enter in front of the shoulder
- Be aware of body rotation at the catch. You only want to roll about 20-30 degrees to each side, to limit shoulder impingement at the catch
- Think about your hand-elbow position at the catch too. As you start to pull, try to get your hand deeper than your forearm ASAP. The elbow stays out slightly wider than the hand, and it’s a straight pull from there at shoulder width – not an ‘S’ pull
Some signs to look for when you’re getting tired in freestyle that put stress on the shoulder are:
- Longer breaths
- Bigger rotations
- Dropped elbow when you initiate the pull
Warm up exercises
Finally, a good warm up before you get in the water can help you ‘wake up’ your rotator cuff and shoulder complex, so they are ready to work when you hit the water. See this video for demonstrations.
- Bilateral external rotation with elbows at your side x 30 reps
- Chicken wing with the back of your hands on your low back along the top of your hip bones. Push elbows forward and backward x 30 reps
- Bilateral external rotation at 90 degrees. Hands and forearms start parallel to floor at shoulder height, then rotate to goal post position & back to horizontal x 30 reps
- Shoulders & elbows flexed to 90 degrees. Maintain that position while horizontally adducting and abducting the arms x 30 reps
- Streamline position then drop elbows back & down to ‘I didn’t do it’ position x 30 reps
By Juliann Desjardins
M.Phty, M.A (Kin), B.A (Kin), APAM.
Juliann is an OceanFit instructor and physiotherapist.